DME MACs Announce Directions for Upgrade Modifiers

The DME MACs have issued instructions for providers who want to use upgrade modifiers to resubmit claims that were previously denied for “least costly alternative” reasons.

According to a bulletin issued last week by CIGNA Government Services, the Jurisdiction C DME MAC: “For certain items that were previously subject to LCA (least costly alternative), suppliers will now receive a ‘not reasonable and necessary’ denial.”

If the claim regarded items previously subject to the LCA rule, CIGNA said, “Suppliers have the option of resubmitting the claim using the upgrade modifiers and the code for the covered medically necessary item rather than exercising the option of Appeals.”

As an example, CIGNA used a claim for a fully electric hospital bed (HCPCS code E0265): “A supplier submits a claim after Feb. 4, 2011 for code E0265, and the claim is denied as not reasonable and necessary. That claim may be resubmitted with code E0265 and the appropriate modifiers on Line 1 and code E0260 and the appropriate modifiers on Line 2. Resubmitting the claim in this fashion will not result in a conflict with the original code E0265 claim and subsequent duplicate claim denial.”

CIGNA emphasized that the resubmission instructions “apply only to items previously subject to LCA payment policy that now receive not reasonable and necessary denials. Other items receiving reasonable and necessary denials must follow the usual redeterminations process.”

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.